bhu ncd action plan 2015 2020
Royal Government of Bhutan
THE MULTISECTORAL NATIONAL ACTION PLAN FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES
[2015-2020]
This document was granted approval during the 80th Lhengye Zhungtshog session held on 6th July
2015.
“Attainment of the highest standard of physical, mental and social wellbeing for all Bhutanese by
adopting healthy lifestyles and reducing exposures to risk factors that contributes to NCDs”
ACKNOWLEDGEMENTS
The document was prepared with the technical and financial support of the World Health Organization. Special thanks to Dr. Poonam Khetrapal Singh, Regional Director, SEARO and Dr. Oleg Chestnov, Assistant Director General for Noncommunicable Diseases and Mental Health, WHO, HQ for their support in the process of development of the action plan.
Stakeholders consulted
• Bhutan Agriculture and Food Regulatory Authority • Bhutan Broadcasting Service • Bhutan Narcotic Control Agency • Bhutan Olympic Committee • Department of Youth and Sports, Ministry of Education • Drastang Lhengtshog • Druk Fitness Center, Thimphu • Gewog Administrations of Chang and Mewang, Thimphu Dzongkhag • Gross National Happiness Commission • Khesar Gyalpo University of Medical Sciences of Bhutan • Ministry of Economic Affairs • Ministry of Finance • Ministry of Health • Ministry of Works and Human Settlements • Road Safety And Transport Authority • Thromde Administrations of Gelephu, Phuntsholing, Thimphu and Samdrupjongkhar • Zilukha Middle Secondary School, Thimphu
Core writing team
1. Dr. Gampo Dorji, NCD Division, Department of Public Health, Ministry of Health
2. Dr. Evgeny Zheleznyakov, WHO Consultant
3. Dr. Habib Benzian, WHO Consultant
Reviewers and contributors
1. Dr. Pandup Tshering, Director, DoPH, MoH
2. Dr. Ornella Lincetto, WHO Representative, Country Office, Bhutan
3. Dr. Renu Garg, Regional Advisor for NCDs, WHO SEARO
4. Mr. Tandin Dorji, Chief Program Officer, NCD, DoPH, MoH
5. Mr. Tshering Dhendup, Head, Health Research Unit, PPD, MoH
6. Mr. Rinchen Namgay, Deputy Chief Program Officer, DMS, MoH
7. Ms. Dechen Wangmo, WHO Consultant
8. Mr. Nima Gyeltshen, Deputy Chief Program Officer, DYS, MoE
9. Ms. Tashi Yangzom, Regulatory and Quarantine Officer, Quality Control and Quarantine Division, BAFRA, MoAF
10. Mr. Chhimi Dorji,Senior Program Officer, BNCA
11. Dr Nima Wangchuk, WHO Country Office for Bhutan
Secretariat
1. Mr. Wangchuk Dukpa, Senior Program Officer, LSRDP, Ministry of Health
2. Ms. Karma Doma, Deputy Chief Program Officer, LSRDP, Ministry of Health
Special Editor
Dr. Wesley Chodos, Clinical Assistant Professor, Drexel University College of Medicine, Philadelphia, USA
ABBREVIATIONS
BAFRA
Bhutan Agriculture and Food Regulatory Authority
BHU
Basic Health Unit
BMED
Biomedical Engineering Division
Bhutan Narcotics Control Agency
CVD
Cardiovascular Disease
DYS
Department of Youth and Sports
FYP
Five Year Plan
FCTC
Framework Convention for Tobacco Control (WHO)
GNHC
Gross National Happiness Commission
HPD
Health Promotion Division
HR
Human Resources
KGUMS
Khesar Gyalpo University of Medical Sciences
LSRDP
Lifestyle Related Disease Program
MoE
Ministry of Education
MoAF
Ministry of Agriculture and Forests
MoH
Ministry of Health
MoWHS
Ministry of Works and Human Settlement
MHP
Mental Health Programme
MSPD
Medical Supplies Procurement Division
NCD
Noncommunicable Disease
NSC
National Steering Committee
PEN
Package of essential non communicable disease interventions
PMSG
Performance Monitoring System of Government
SEARO
South East Asian Regional Office
WHA
World Health Assembly
WHO
World Health Organization
SECTION I BACKGROUND SITUATION
1.1 Introduction
Noncommunicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression. NCDs – mainly cardiovascular diseases, diabetes, cancers and chronic respiratory diseases (Asthma and obstructive pulmonary diseases (COPDs) – are the world’s biggest killers. More than 36 million people die annually from NCDs (63 of global deaths), including 14 million people between the ages of 30 and 70 who die young. Approximately three quarters of NCD deaths - 28 million - occur in low- and middle-income countries. [1]
All age groups are affected by NCDs. NCDs are often associated with older age groups, however, WHO evidence shows that 16 million of all deaths globally attributed to NCDs occur before the age of 70. Of these “premature” deaths, 82 occurred in low- and middle-income countries. Children, adults and the elderly are all vulnerable to the risk factors that contribute to noncommunicable diseases, whether from unhealthy diets (high salt, high fat and low consumption of fruits and vegetables), physical inactivity, tobacco use or harmful use of alcohol.
These behaviors lead to four key metabolicphysiological changes that increase the risk of NCDs: raised blood pressure, overweightobesity, hyperglycemia (high blood glucose levels) and hyperlipidemia (high levels of fat in the blood). In terms of attributable deaths, the leading metabolic risk factor globally is elevated blood pressure (to which 18 of global deaths are attributed) followed by overweight and obesity and raised blood glucose. Low- and middle-income countries are witnessing the fastest rise in overweight and obesity young children.
To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, education, agriculture, planning, media and many others, to work together to reduce the risks associated with NCDs, as well as to promote the interventions to prevent and control them.
1.2 NCD Prevention and Control- Approaches
An important way to reduce NCDs is to focus on lessening the risk factors associated with these diseases. Low-cost solutions exist to reduce the common modifiable risk factors (mainly tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol). This is called primary prevention that can be carried out at population level and individual level. Other ways to reduce NCDs are high impact essential NCD interventions that can be delivered through a primary health-care approach to strengthen early detection and timely treatment (secondary prevention). Evidence shows that such interventions are excellent economic investments because, if applied early, can reduce the need for more expensive treatment. One of the effective approaches to primary prevention of NCDs is promotion of heath in places and social contexts known as ‘Healthy Settings’ [2].
Healthy Setting interventions can be targeted at schools, work sites, hospitals, cities and villages. Action to promote hea lth through different settings can take many forms. Actions often involve some level of organizational development, including changes to the physical environment or to the organizational structure, administration and management. These settings can also be used to promote health as vehicles to reach individuals and gain access to services. Healthy Settings is a useful, dynamic method to integrate risk factors and address NCD prevention with active involvement of administration and management. These settings can also be used to promote health as vehicles to all sectors, not only health. For example, promotion of physical activity in population would require reach individuals and gain access to services. Healthy Settings is a useful, dynamic method to
not only raising awareness of the benefits of physical activity but also creating the environment and integrate risk factors and address NCD prevention with active involvement of all sectors, not only
health. For example, promotion of physical activity in population would require not only raising
conditions that will enable people to be physically active. Creating an enabling environment in this awareness of the benefits of physical activity but also creating the environment and conditions that case will include urban planning and solutions for facilitating practicing sports, running, jogging, safe will enable people to be physically active. Creating an enabling environment in this case will include pedestrian walking, recreational areas, public transport, school facilities, local administrations and urban planning and solutions for facilitating practicing sports, running, jogging, safe pedestrian private sector role in organizing sports events, competitions, and others. Underlying determinants, walking, recreational areas, public transport, school facilities, local administrations and private sector such as social determinants of health (economic situation, poverty, environment factors, etc.), as well role in organizing sports events, competitions, and others. Underlying determinants, such as social
determinants of health (economic situation, poverty, environment factors, etc.), as well as ageing of
as ageing of population, globalization and urbanization, should be taken into consideration in finding population, globalization and urbanization, should be taken into consideration in finding the the appropriate solutions. (Figure 1) appropriate solutions. (Figure 1)
hig her
He alth
Int Se erv
en cto tio r in nC volv ost s em en t
low er
Figure 1: Determinants of NCDs, related cost of interventions and respective health sector involvement (Modified from SEA Figure 1: Determinants of NCDs, related cost of interventions and respective health sector
involvement (Modified from SEA Regional NCD Action Plan) Regional NCD Action Plan) Interventions and actions with the highest population impact are those tackling issues at the bottom
Interventions and actions with the highest population impact are those tackling issues at the bottom
of the pyramid; they are in general also more cost-effective and involve a broad range of sectors and
of the pyramid; they are in general also more cost-effective and involve a broad range of sectors and
stakeholders. Interventions and actions at the higher areas of the pyramid that focus more on the
stakeholders. Interventions and actions at the higher areas of the pyramid that focus more on the health sector become more costly and are more directed towards high-risk populations or health sector become more costly and are more directed towards high-risk populations or individuals, individuals, rather than whole populations. rather than whole populations.
The main focus of this action plan is on four types of NCDs — cardiovascular diseases, cancer, chronic respiratory diseases and diabetes - which make the largely contributes to morbidity and mortality
The main focus of this action plan is on four types of NCDs — cardiovascular diseases, cancer, chronic
due to NCDs, and in addition to shared behavioral risk factors — tobacco use, unhealthy diet,
respiratory diseases and diabetes - which make the largely contributes to morbidity and mortality due
physical inactivity, harmful use of alcohol and indoor air pollution. Recognizing that the conditions in
to NCDs, and in addition to shared behavioral risk factors — tobacco use, unhealthy diet, physical
which people live and work influence their health and quality of life.
inactivity, harmful use of alcohol and indoor air pollution. Recognizing that the conditions in which
people live and work influence their health and quality of life. 1.3 NCD Burden and Risk Factors in Bhutan
Considerable gains have been made in Bhutan in maternal and child health, immunization, and
2 prevention and control of communicable diseases, however, the prevalence of non-communicable
1.3 NCD Burden and Risk Factors in Bhutan
Considerable gains have been made in Bhutan in maternal and child health, immunization, and prevention and control of communicable diseases, however, the prevalence of non-communicable diseases (NCDs) has risen considerably, and now account for about 70 of the reported burden of disease according to the WHO estimates. This rising trend is due largely to changes in lifestyle, dietary habits, global marketing of unhealthy products, and aging population. NCDs cause the highest proportion of deaths for all age groups and account for 53 of all deaths. Among deaths caused by NCDs, cardiovascular diseases are responsible for the majority of cases (28), followed by cancer (9), respiratory diseases (6) and diabetes (2). Rapid urbanization and modernization have
increased deaths from road accidents and in addition the incidence of mental disorders, substance NCDs, cardiovascular diseases are responsible for the majority of cases (28), followed by cancer abuse, suicides and violence are increasing. (9), respiratory diseases (6) and diabetes (2). Rapid urbanization and modernization have
increased deaths from road accidents and in addition the incidence of mental disorders, substance abuse, suicides and violence are increasing.
Bhutan is in the early stages of a demographic transition with a growing elderly population resulting in a steady increase in NCDs. The population projection estimates, that there will be a rise in the Bhutan is in the early stages of a demographic transition with a growing elderly population resulting population 65 years and above from 4.4 to 7.3 by 2025.[3] This requires a renewed and focused in a steady increase in NCDs. The population projection estimates, that there will be a rise in the approach in risk factor reduction, prevention, control and management of NCDs, both within and population 65 years and above from 4.4 to 7.3 by 2025.[3] This requires a renewed and focused outside of the health sector. approach in risk factor reduction, prevention, control and management of NCDs, both within and Based on the available health data, NCDs cause the highest proportion of deaths for all age groups outside of the health sector. (Figure 1). This makes NCDs Bhutan’s biggest health challenge. Based on the available health data, NCDs cause the highest proportion of deaths for all age groups
(Figure 1). This makes NCDs Bhutan’s biggest health challenge.
Figure 2: Proportional structure of mortalityall ages (Source: WHO NCD Country Profile 2011)
Figure 2: Proportional structure of mortalityall ages (Source: WHO NCD Country Profile 2011) With the low capacity of the current health system to provide sophisticated tertiary care in Bhutan,
patients with advanced or complicated conditions requiring specialist care such as complications of
With the low capacity of the current health system to provide sophisticated tertiary care in Bhutan, diabetes, kidney diseases, heart diseases, organ transplantation or cancer treatment are referred to patients with advanced or complicated conditions requiring specialist care such as complications India by the state. The numbers of referral cases and costs have increased significantly from 529 of diabetes, kidney diseases, heart diseases, organ transplantation or cancer treatment are referred patients and a cost Nu 81 million in 2006-2007 to 1047 patients and Nu 180 million in 2012-2013. [4] to India by the state. The numbers of referral cases and costs have increased significantly from 529 The majority of these referrals are due to advanced NCDs. patients and a cost Nu 81 million in 2006-2007 to 1047 patients and Nu 180 million in 2012-2013. [4]
The majority of these referrals are due to advanced NCDs. Risk Factors
a)Harmful use of alcohol: Alcohol use is causally linked to 60 different types of diseases. It can cause harm to the well-being and health of people associated or living with the drinker through intentional and unintentonal injuries and adverse socio-economic consequences. Alcohol is widely consumed in
Risk Factors
a) Harmful use of alcohol: Alcohol use is causally linked to 60 different types of diseases. It can
cause harm to the well-being and health of people associated or living with the drinker through intentional and unintentonal injuries and adverse socio-economic consequences. Alcohol is widely consumed in Bhutan. The per capita consumption of alcohol is 8 liters as compared to the global consumption of 6.2 liters of pure alcohol per person 15 years and older. The Bhutan’s National Health Survey 2012 found that 28.5 of the population aged 10-75 years were current drinkers and drinking was more common in males (31 in males versus 18 in females). Current drinkers spent, Nu. 594 a month on the average, and spending was higher among urban residents compared to rural counterparts. Ara and bangchangsingchang (locally brewed alcohol) were the most widely used drinks for rural residents, while beer and liquor such as whiskeyrum were the main drinks for urban residents.[3] Given the ease of access, low prices, home brewing and cultural acceptability of the use of alcohol, innovative alcohol control policy implementation is necessary for Bhutan.
b) Unhealthy diet: Adequate consumption of fruit and vegetables reduces the risk for cardiovascular
diseases, stomach cancer and colorectal cancer. An unhealhty diet in Bhutan comprises all three main components resulting in– low consumption of fruits and vegetables, high intake of salt sodium, and high consumption of saturated fats and trans fats. At least 67 of Bhutanese do not consume sufficient fruits and vegetables. [5] Consumption of high levels of high-energy foods, such as processed foods high in fats and sugars, promotes obesity compared to low-energy foods such as fruits and vegetables.
The amount of dietary salt and sodium consumed is an important determinant of blood pressure levels and overall cardiovascular risks. The average daily intake of salt in Bhutan is 9 gms signficantly higher than the WHO recommended daily intake of less than 5 gms. This practice can have a major impact on blood pressure and cardiovascular disease. High consumption of saturated fats and trans-fatty acids is linked to heart disease; replacement with polyunsaturated vegetable oils lowers coronary heart disease risk. Higher unsaturated fatty acids from vegetable sources and polyunsaturated fatty acids have also been shown to reduce the risk of type 2 diabetes.
c) Physical inactivity: is one of the major risk factors for NCDs and a fourth leading cause of global
mortality. The National health Survey in Bhutan found that 25.5 of the population aged 10-
75 years do sportsfitness or recreational activities on the average of 3 days per week and 1.6 hours per day.[3] Physical inactivity levels are likely to be higher in urban settings than rural population because rural lifestyle can coincidentally contribute to the required level of physical activity during the daily farm work.
d) Tobacco use: Globally, tobacco is the greatest cause of preventable death. It is a major risk factor
for non-communicable diseases such as strokes, heart attacks, chronic obstructive pulmonary disease, cancer, hypertension and peripheral vascular disease. The STEPS survey conducted in
Bhutan demonstrated that, 7.4 smoked tobacco (11 of men and 3 of women), lower than the smoking rates in the neighboring countries. However, 19.7 use smokeless tobacco. [5] The survey also reported high exposure to second hand smoke at home and the work place despite strong tobacco laws.[6] The 2013 Global Youth Tobacco Survey (GYTS) conducted in Bhutan among 13-15 year old school children, documented a current user rate of 30.3 for tobacco product, of which 14 reported smoking cigarettes. [7]
e) Doma use: Chewing of doma (betel nut and leaf) is a widespread tradition among Bhutanese. Approximately 250,000 Bhutanese (60 of the adult population) chew doma and a practice equally prevalent among males and females (51 of women as compared to 47 men).[8] The International Agency for Research on Cancer (IARC) concluded that the betel nut is carcinogenic. [9] Various compounds present in the nut, most importantly arecoline (the primary psychoactive ingredient), contribute to histologic changes in the oral mucosa. Doma is a powerful risk factor for oral cancer. The new evaluation of betel nut without tobacco was made possible by recent epidemiologic studies from parts of the world where tobacco generally is not added to the betel quid. In addition, recent epidemiologic studies in South Asia have been able to separate the effects of betel quid use with and without tobacco. Oral cancers are more common in parts of the world where betel nut is chewed. Of the 390,000 oral and oropharyngeal cancers estimated to occur annually in the world, 228,000 (58) occur in South and South-East Asia.[9] In addition, doma is directly associated with NCDs. A large meta-analysis confirms that doma use is associated with an increased risk of metabolic disease, cardiovascular disease, and all-cause mortality: studies from Asia covering 388,134 subjects were selected. A significant dose-response relationship was shown between doma consumption and the risk of events – obesity, metabolic syndrome, diabetes, hypertension and all-cause mortality. Recent studies in Asia have shown that doma chewing is significantly increasing the risk of coronary heart disease and atrial fibrillation. Doma use have also been shown to affect most organs of the human body including the brain, heart, lungs, gastrointestinal tract and reproductive organs.[9]
f) Indoor air pollution: Indoor cooking and heating with biomass fuels (agricultural residues, dung, straw, wood) or coal produces high levels of indoor smoke containing a variety of health- damaging pollutants. There is consistent evidence that exposure to indoor air pollution can lead to acute lower respiratory infections in children under five, and chronic obstructive pulmonary disease and lung cancer (where coal is used) in adults.
g) Raised blood pressure, raised blood sugar, overweight and obesity:
In combination with other components of an unhealthy diet (high salt and fats consumption), 36 of Bhutanese people have raised blood pressure, and 27 men and 40 women are overweight or obese.[5]
1.4 Policy Rationale
In 2013, the 66 th World Health Assembly adopted the Global Action Plan for Prevention and Control of NCDs 2013–2020, containing a comprehensive monitoring framework with 25 indicators and 9
voluntary global targets for NCDs. [1]The document was adopted during the 66 th meeting of the WHO SEA Regional Committee in New Delhi with slight modification by adding a tenth target on indoor
air pollution to the global targets.[10] On the same occasion the SEA Regional Committee adopted the New Delhi Declaration on High Blood Pressure. In addition to these policies, the first-ever SEA Regional Oral Health Strategy has been developed to address the increasing burden of oral diseases such as tooth decay and oral cancer, and also contribute to reducing the burden of other NCDs.
The Royal Government of Bhutan’s concern for health in general and NCDs in particular is deeply anchored in a number of important national policies The Government’s commitment in the provision of free and quality universal health care is guided by the Section 21 and 22 under Article 9 of the Constitution of the Kingdom of Bhutan guaranteeing its citizens “free access to basic public health services in both modern and traditional medicines” and “security in the event of sickness and disability”. The National Health Policy recognizes NCDs as a public health problem for the country and outlines key broad policy statements. The country’s Five Year Plan (FYP) provides and inclusive NCD prevention and control by “creating awareness on noncommunicable diseases and initiating programmes to promote healthy lifestyles”. Even before the regional movement, Bhutan was one of the few countries in the region to adopt the National Policy and Strategic Framework for the Prevention and Control of Noncommunicable Diseases in 2009 led by the Ministry of Health.[11]
1.5 Achievements and Opportunities
Leadership, Advocacy, Partnerships
Bhutan has adopted a number of policies and regulations that address the prevention and control of NCDs, particularly the National Policy and Strategy Framework on Prevention and Control of NCDs in 2009. The National Steering Committee for Lifestyle Promotion and Prevention of NCDs was formed at the same time at the Ministry of Health for leading, coordinating and reviewing policy implementation. The National Steering Committee has not yet exercised its mandate as envisioned in the NCD Policy.
A signing of the commitment to NCD prevention and control was conducted among parliamentarians and policy makers in 2010. A nationwide “Move for Health Campaign” is conducted routinely led by the Prime Minister, to educate the population on prevention on NCDs. The Central Monastic Body and Ministry of Health started collaborative projects for health programs in the religious sector since 1989, addresses NCDs and lifestyle promotion by advocating among high ranking Lams, Lopens and Uzins including training of monk health representatives. The district health services conducts outreach visits to the monastic institutions to provide a monthly check up and screening for hypertension and other NCD risks. The Ministry of Education implements health education and prohibits alcohol and tobacco use in schools through policies of “zero tolerance to alcohol and drugs” in school campuses. [12] Physical activity promotion programs are implemented in schools and have dedicated physical A signing of the commitment to NCD prevention and control was conducted among parliamentarians and policy makers in 2010. A nationwide “Move for Health Campaign” is conducted routinely led by the Prime Minister, to educate the population on prevention on NCDs. The Central Monastic Body and Ministry of Health started collaborative projects for health programs in the religious sector since 1989, addresses NCDs and lifestyle promotion by advocating among high ranking Lams, Lopens and Uzins including training of monk health representatives. The district health services conducts outreach visits to the monastic institutions to provide a monthly check up and screening for hypertension and other NCD risks. The Ministry of Education implements health education and prohibits alcohol and tobacco use in schools through policies of “zero tolerance to alcohol and drugs” in school campuses. [12] Physical activity promotion programs are implemented in schools and have dedicated physical
The Bhutan Olympic Committee advocates for physical activity and organizes national events such as annual marathon and promotion of sports and sporting facilities. BOC’s role would be crucial in developing sports infrastructure, training cadres of fitness experts, and enhancing health promotion at the population while promoting excellence in key areas. In general more investment is needed to train physical activity trainers, and dieticians to provide services in the population.
Improving urban built environment is a key measure to promote healthy settings in a rapidly increasing urbanization. National standards and designs for urban structures strive for continuous improvement and innovation through incorporation of improved walkability, connectivity and provision of parks and public spaces in urban settlements by the Ministry of Works and Human Settlements.
Health promotion and risk reduction
Information on NCD prevention is disseminated through mass media managed by the MoH and by health workers through health talks at the community level. However, more targeted and rigorous behavior change campaigns (BCC) to promote healthy lifestyle and to minimize exposure to NCD risk factors to bring about a positive behavioral change at the population level. The National Health Promotion Strategy 2013-2023 recognizes NCDs as a top priority and will provide a multisectoral umbrella for other sectors to include “health in all policies”.[13]
There are a number of legislations related to addressing tobacco and alcohol control. Additional framework to reduce harmful use of alcohol is already submitted to the Cabinet and once approved it will serve as a powerful tool for reducing harmful alcohol use. Enforcement of these policies is patchy and the potential impact of related legislation thus limited.
The promotion of physical activity remains a challenge. The National Recommendations for physical activity and diet remains unimplemented despite the documents endorsed in 2011.[14][15] Of note are the huge unreached urban communities with sedentary lifestyle living within the vicinity of health facilities. Community-based programs for health promotion have to be intensified and focused on such communities. In the absence of active community based groups, the health sector with the collaboration of the local governments should take a lead role in establishing active community social mobilization for health promotion. Such activities could motivate community members to undertake physical activity, conduct community events for health promotion, improve urban built environment and promote use of physical fitness centers.
Similarly, children and young people should be educated and provided with opportunities for adoption of healthy habits early in life. Schools and families will play the most important role in providing learning opportunities for them. Mass drills and aerobics should be included in school activities to ensure mass physical activity promotion. Families should include healthy lifestyle models as a part of their living. A concept of healthy schools should be piloted and eventually promoted in all schools.
A number of pilot programs such as Community Action for reducing alcohol use in Mongar, Lhuentse dzongkhags have been implemented.[16] These experiences are being scaled up in other districts of Pemagatsel, Zhemgang and Trongsa that have traditional high use of alcohol. Rigorous evaluation and assessment of these projects should be conducted to facilitate learning and scaling-up.
Health system strengthening
The health system should aim at improving prevention, early detection, risk factor and disease management of people with or at high risk of NCDs. The current free health services provide equal access including provision of essential NCD medicines. However, with the anticipated rise in the NCD burden, the number of health professionals, as well as the level of trainings will be inadequate to address the health system response. Of the 20 district, only 11 districts have at least 3 doctors each,
5 districts have 2 doctors and the remaining 4 district has only one doctor for the whole district in 2013. [17]Greater priority needs to be given to human capacity building on NCD prevention, control and management in terms of the number and depths of training for health care providers. Medical specialists are scarce and establishments of the Khesar Gyalpo University of Medical Sciences (KGUMS) provides opportunity for systematic professional development activities specifically related to NCDs. Links with the deeply rooted traditional medicine facilities have not been optimally used for synergistic activities in health promotion and disease screening.
Current in-service and pre-service NCD curriculum in Bachelors of Public Health (BPH), and Health Assistant Courses at the Faculty of Nursing and Public Health (FNPH) is a sustainable institutional approach for mainstreaming NCD education. Health workers training on PEN interventions conducted by the MoH provides skills enhancing opportunity of in-service health workforce. Refreshers courses and trainings will be required for maintenance of health workforce skills in the future. Healthy diet and lifestyle are partially covered through ANC education in MCH clinics but have not been subjected to sound evaluation to assess the benefits of the programs. Diabetic services set up with the grant support of the World Diabetic Foundation have been integrated as a routine service. Also pilot NCD and elderly care programs have been expanded across the country. Hospital systems will not only need to be adequately equipped to provide high quality, equal services to prevent premature deaths, NCD palliative care services, such as oncology, cardiac and nephrology services will need to be strengthened to provide advanced care for people living with NCDs.
Surveillance, monitoring and evaluation and research
The Ministry of Health’s Health Management Information System (HMIS) collects and publishes annual disease morbidity and mortality. The MoH relies on periodic STEPS Survey and other surveys for risk factor surveillance. Existing STEPS data sets should be further analyzed to understand The Ministry of Health’s Health Management Information System (HMIS) collects and publishes annual disease morbidity and mortality. The MoH relies on periodic STEPS Survey and other surveys for risk factor surveillance. Existing STEPS data sets should be further analyzed to understand
Surveillance on policy implementation on alcohol and tobacco is necessary to assess progress on policy compliance and pilot projects. Policy enforcement and compliance monitoring should be adopted as broader systems response for NCD prevention.
A robust NCD surveillance system should be established by setting up disease registries to monitor premature NCD deaths. If such a routine system is not set up, periodic surveys should be conducted to document the burden of NCD deaths and premature mortality. To begin with, cancer registry, which is still in a pilot stage in JDWNRH should be fully operationalized and expanded to other regional hospitals.
Furthermore, NCD innovations in healthy lifestyle promotion and other interventions should be explored through implementation of pilot programs. Priority programs include community based NCD outreach programs for unreached urban communities, healthy work place and healthy school projects. Such pilot programs should be rigorously implemented and evaluated, before proceeding for
a national scale up.
SECTION II GOAL, OBJECTIVES, AND ACTION AREAS
2.1 Goal
To reduce the preventable and avoidable burden of morbidity, mortality and disability due to non- communicable diseases through multisectroal collaboration and cooperation at the national, dzongkhags, gewogs and community levels.
2.2 Objectives
• To raise awareness of NCDs and advocate for their prevention and control; • To promote implementation of efficient measures and interventions to reduce major risk
factors for NCDs specifically: harmful use of alcohol, tobacco use, unhealthy diet and physical inactivity and their determinants among the population;
• To promote effective partnerships for the prevention and control of NCDs including injury
control and safety promotion; • To ensure equitable access to health facilities that provide quality, evidence-based
preventive, treatment and rehabilitative services; and • To strengthen research for prevention and control of NCDs and their risk factors.
2.3 Guiding Principles
The prevention and control of NCDs and their risk factors will be guided by the following principles:
• A focus on major modifiable risk factors and their determinants; • Application of a life course approach addressing changing needs of different age groups as
they move through subsequent stages of life; • An integrated approach combining population-based and high-risk strategies; • Shared responsibility by relevant sectors and stakeholders; • Prioritization of cost-effective and evidence-based intervention; • Application of a stepwise approach in the implementation of the NCD program taking into
consideration the status of development of the health system and availability of resources; and
• Provision of the equitable access to health care to all, based on health needs and not on the
ability to pay.
Furthermore, the National Policy and Strategic Framework for the Prevention and Control of Non- communicable Diseases also explicitly lay out four key broad measures for control and prevention of NCD. [11]
• Integration of NCD prevention activities into plans and program of relevant sectors; • Reinforce existing policies and regulation for NCD; • Promote health life style initiative through strategic health promotion; • Strengthen health services to provide timely treatment and a continuum of care.
The Action Plan proposes time bound priority activities which are guided by the National Policy and Strategic Framework for the Prevention and Control of Non-communicable Diseases. Several other The Action Plan proposes time bound priority activities which are guided by the National Policy and Strategic Framework for the Prevention and Control of Non-communicable Diseases. Several other
• Tobacco Control Act (2010) and Tobacco Control Rules and Regulations (2013) • Bhutan National Health Promotion Strategic Plan 2013-2023 • Domestic violence prevention Act (2012) • Health Promotion Policy • National Health Policy • National Policy and Strategic Framework to Reduce the Harmful Use of Alcohol • National Drug Policy (2007) and Bhutan Essential Drug List (2013) • Village Health Worker Program: Policy and Strategic Plan 2013-2018 • Package of Essential NCD (PEN) Protocol for BHUs (2013) • Bhutan Food Based Dietary Guidelines (2011) • National Physical Activity Recommendations for Bhutan • Guidebook for School Health Coordinators (MoH MoE, 2007) • National Occupational Health and Safety Policy (2012) • Food and Nutrition security policy (2012)
2.4 Action Areas
The Bhutan National Action Plan for NCD Prevention and Control 2015-2020, recognizes the recommendations and principles outlined in the SEA Regional Action Plan for the Prevention and Control of NCDs and Bhutan National Health Promotion Strategic Plan 2013-2023, and endorses the four areas of priority action:
Action area 1: Advocacy, partnerships and leadership. Actions under this area aim to increase advocacy, promote multisectoral partnerships and strengthen capacity for effective leadership to accelerate and scale-up the national response to the NCD epidemic. Effective implementation of these actions should result in increased political commitment, availability of sustainable resources, and setting functional mechanisms for multisectoral actions and effective coordination by ministry of health.
Action area 2: Health promotion and risk reduction. Actions under this area aim to promote population wide programs for effective implementation of NCD risk factors which should lead to reduction in tobacco use, increased intake of fruits and vegetables, reduced consumption of saturated fat, salt and sugar, reduction in harmful use of alcohol, increase in physical activity, reduction in household air pollution and discourage doma ( betel quid consumption.
Action area 3: Health systems strengthening for early detection and management of NCDs and
their risk factors. Actions under this area aim to strengthen health systems, particularly the primary health care system. Full implementation of actions in this area should lead to improved access to health-care services, increased competence of primary health care workers to address NCDs, and empowerment of communities and individuals for self-care.
Action area 4: Surveillance, monitoring and evaluation, and research. This area includes key actions for strengthening surveillance, monitoring and research. The desired outcome is to improve availability and use of data for evidence-based policy and program development
2.5. National NCD Targets for Bhutan
The Action Plan endorses the SEA Regional NCD Action Plan’s ten voluntary targets to be achieved by 2025 and sets medium term targets to be achieved by 2020 as shown in the table below:
Table 1: NCD Targets for 2020 and 2025
Target areas
Relative reduction in risk of premature mortality from cardiovascular diseases, cancer,
diabetes, or chronic respiratory diseases Relative reduction in the harmful use of alcohol
Relative reduction in prevalence of current tobacco use in persons aged over 15 years
Relative reduction in prevalence of insufficient physical activity (in urban population)
Relative reduction in mean population intake of saltsodium
Relative reduction in prevalence of raised blood pressure
Halt the rise in obesity and diabetes
..... 0 rise
Eligible people receive drug therapy and counseling (including glycemic control) to prevent
heart attacks and strokes Availability of affordable basic technologies and essential medicines, including generics,
required to treat major NCDs in public facilities Relative reduction in the proportion of households using solid fuels (wood, crop residue,
dried dung, coal and charcoal) as the primary source of cooking in urban population
2.6. Priority Action Areas
Strategic action area 1: Advocacy, partnerships, and leadership Action area: 1.1. Advocacy
Raise awareness on NCDs by informing politicians and policy makers on NCD and the major risk factors
Action area: 1.2. Partnerships
Strengthen the National NCD Steering Committee and develop multisectoral procedures and structures between key partners, beginning with the most relevant and motivated ministries
Action area: 1.3. Leadership
Ensure highest political leadership and commitment for NCDs (Head of state, Ministers etc) by identifying existing and creating new opportunities to speak publicly, participate in national and international conferences, showcase achievements and host NCD related events
Strategic action area 2: Health promotion and risk reduction Action area: 2.1. Reduce tobacco use
Improve enforcement of all aspects outlined in the updated Tobacco Control Rules and Regulations (2013) through effective partnerships with police, border police, customs and other enforcement entities
Action area: 2.2. Reduce harmful use of alcohol
Accelerate the implementation of strategies to reduce the harmful use of alcohol by strengthening the enforcement of existing alcohol legislation including a ban on alcohol advertising and promotions and public education on harmful effects of alcohol
Stepwise increase of taxation on all alcohol products for the next 5 years
Action area: 2.3. Promote a healthy diet
Develop and implement a national salt reduction strategy Obligate appropriate industries, importers and retailers to reduce amount of salt and sugar in their products
through appropriate policies and legislation (based on the national salt reduction strategy)
Action area: 2.4. Promote physical activity
Advocate the importance of physical activity for health among legislators, decision-makers, urban planners, par- ents, teachers, health workers, employers, religious leaders and support built environment and services for health promoting physical activities
Action area: 2.5. Promote healthy behaviors and reduce exposure to risk factors in key settings
Regulate foods high in saturated fat, sugar and salt from school premises and workplace facilities through advo- cacy, appropriate regulations and enforcement; and introduce healthy workplace and Health Promoting Schools, and Healthy hospitals
Action area: 2.6. Reduce household air pollution
Scale up programs aimed at encouraging the use of improved cook-stoves, good cooking practices, reducing expo- sure to fumes, and improving ventilation in households among high priority communities
Strategic action area 3: Health system strengthening for early detection and management of NCDs and their risk factors
Action area: 3.1. Access to Health Services
Develop a scale-up plan for general introduction of the Package of Essential Non-communicable (PEN) Disease Interventions in all Basic Health Units (BHU)
Action area: 3.2. Health workforce
Integrate NCDs in the training curricula for future primary health care workers and allied personnel
Action area: 3.3. Community-based approaches
Work with existing community organizations to pilot programmes targeting tobacco, alcohol, diet and physical activity to strengthen community engagement with NCD programmes
Strategic action area 4: Surveillance, monitoring and evaluation and research Action area: 4.1. Strengthen surveillance
Strengthen collection of demographic data as well as age- and cause of death data using verbal autopsy tools through improvement of civil registration and vital statistics
Action area: 4.2. Improve monitoring and evaluation
Develop and establish simple and effective mechanisms to monitor progress in all priority areas of the National NCD Action Plan
SECTI
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